National Trends in Timing of Death Among Patients With Septic Shock, 1994–2014 Objectives: To assess trends in timing of mortality among patients with septic shock. Design: Retrospective cohort study. Setting: Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project’s National Inpatient Sample, 1994–2014. Patients: Hospitalized adults (≥ 18 yr) with International Classification of Diseases, 9th Edition, Clinical Modification codes consistent with septic shock; secondary analysis: adults with International Classification of Diseases, 9th Edition, Clinical Modification codes consistent with acute respiratory failure receiving invasive mechanical ventilation and patients with both septic shock and acute respiratory failure receiving invasive mechanical ventilation. Interventions: None. Measurements and Main Results: From 1994 to 2014, 48-hour mortality rates decreased among patients with septic shock (21.2% to 10.8%) and septic shock with acute respiratory failure receiving invasive mechanical ventilation (19.1% to 13.4%) but increased among patients with acute respiratory failure receiving invasive mechanical ventilation (7.9% to 9.8%; p value for all trends, < 0.001). Three-to-14-day mortality decreased among patients with septic shock (22.1% to 15.5%), septic shock with acute respiratory failure receiving invasive mechanical ventilation (28.7% to 22.4%) and acute respiratory failure receiving invasive mechanical ventilation (16.8% to 15.0%; p value for all trends, < 0.001). Mortality after 14 days decreased among all groups (septic shock: 12.6% to 6.7%; septic shock with acute respiratory failure receiving invasive mechanical ventilation: 20.3% to 11.3%; and acute respiratory failure receiving invasive mechanical ventilation: 12.7% to 5.8%; p value for all trends, < 0.001). Cox proportional hazard ratio for declining risk in mortality per year (adjusted for patient and hospital characteristics) was 0.96 (95% CI, 0.96–0.96) for septic shock, 0.97 (0.97–0.97) for acute respiratory failure receiving invasive mechanical ventilation and septic shock, and 0.99 (0.99–0.99) for acute respiratory failure receiving invasive mechanical ventilation. Conclusions: Septic shock 48-hour, 3–14-day and greater than 14-day mortality declined markedly over two decades; in contrast, patients with acute respiratory failure only experienced marked decreases in greater than 14-day in-hospital mortality rates. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Law received funding from National Institutes of Health (NIH)/National Institute on Aging (1F32AG058352). Dr. Stevens received funding from Agency for Healthcare Research and Quality (5K08HS024288) and Doris Duke Charitable Foundation. Dr. Walkey received funding from NIH/National Heart, Lung, and Blood Institute (1R01HL136660 and 1R01HL139751) and Boston University School of Medicine Department of Medicine Career Investment Award. For information regarding this article, E-mail: alaw1@bidmc.harvard.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Antibiotic Exposure Profiles in Trials Comparing Intensity of Continuous Renal Replacement Therapy Objectives: To determine whether the probability of target attainment over 72 hours of initial therapy with beta-lactam (cefepime, ceftazidime, piperacillin/tazobactam) and carbapenem (imipenem, meropenem) antibiotics were substantially influenced between intensive and less-intensive continuous renal replacement therapy groups in the Acute Renal Failure Trial Network trial and The RENAL Replacement Therapy Study trial. Design: The probability of target attainment was calculated using pharmacodynamic targets of percentage of time that free serum concentrations (fT): 1) were above the target organism’s minimum inhibitory concentration (≥ fT > 1 × minimum inhibitory concentration); 2) were above four times the minimum inhibitory concentration (≥ % fT > 4 × minimum inhibitory concentration); and 3) were always above the minimum inhibitory concentration (≥ 100% fT > minimum inhibitory concentration) for the first 72 hours of antibiotic therapy. Demographic data and effluent rates from the Acute Renal Failure Trial Network and RENAL Replacement Therapy Study trials were used. Optimal doses were defined as the dose achieving greater than or equal to 90% probability of target attainment. Setting: Monte Carlo simulations using demographic data from Acute Renal Failure Trial Network and RENAL Replacement Therapy Study trials. Patients: Virtual critically ill patients requiring continuous renal replacement therapy. Interventions: None. Measurements and Main Results: The pharmacodynamic target of fT greater than 1 × minimum inhibitory concentration led to similarly high rates of predicted response with antibiotic doses often used in continuous renal replacement therapy. Achieving 100% fT greater than minimum inhibitory concentration is a more stringent benchmark compared with T greater than 4 × minimum inhibitory concentration with standard antibiotic dosing. The intensity of effluent flow rates (less intensive vs intensive) did not substantially influence the probability of target attainment of antibiotic dosing regimens regardless of pharmacodynamic target. Conclusions: Antibiotic pharmacodynamic target attainment rates likely were not meaningfully different in the low- and high-intensity treatment arms of the Acute Renal Failure Trial Network and RENAL Replacement Therapy Study Investigators trials. This work was performed at University of Michigan College of Pharmacy, Ann Arbor, MI. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: muellerb@umich.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

The Case for Broad Subspecialty Training No abstract available

One-Year Outcomes Following Tracheostomy for Acute Respiratory Failure Objectives: Tracheostomy utilization has dramatically increased recently. Large gaps exist between expected and actual outcomes resulting in significant decisional conflict and regret. We determined 1-year patient outcomes and healthcare utilization following tracheostomy to aid in decision-making and resource allocation. Design: Retrospective cohort study. Setting: All California hospital discharges from 2012 to 2013 with follow-up through 2014. Patients: Nonsurgical patients who received a tracheostomy for acute respiratory failure. Interventions: None. Measurements and Main Results: Our primary outcome was 30-day, 90-day, and 1-year mortality. We also determined hospitals readmissions rates and healthcare utilization in the first year following tracheostomy. We identified 8,343 tracheostomies during the study period. One-year mortality following tracheostomy was high, 46.5%. Older adults (≥ 65 yr) had significantly higher mortality compared with younger patients (< 65 yr) (54.7% vs 36.5%; p < 0.0001). Median survival for older adults was 175 days (95% CI, 150–202 d) compared with greater than 1 year for younger adults (adjusted hazard ratio, 1.25; 95% CI, 1.14–1.36). Within 1 year of tracheostomy, 60.3% of patients required hospital readmission. Older adults were more likely to be readmitted in the first year after tracheostomy compared with younger adults (66.1% vs 55.2%; adjusted hazard ratio, 1.19; 95% CI, 1.09–1.29). Total short-term acute care hospital costs (index and readmissions) in the first year after tracheostomy were high (mean, $215,369; SD, $160,874). Conclusions: Long-term outcomes following tracheostomy are extremely poor with high mortality, morbidity, and healthcare resource utilization especially among older patients. Some subsets of younger patients may have better outcomes compared with the general tracheostomy population. Short-term acute care costs were extremely high in the first year following tracheostomy. If extended to the entire U.S. population, total short-term acute care hospital costs approach $11 billion dollars per year for tracheostomy-related to acute respiratory failure. These findings may aid families and surrogates in the decision-making process. This work was performed at National Jewish Health. Dr. Mehta was involved in study design, data analysis, interpretation, and article preparation; he takes full responsibility for the content of the article, data analysis, and data interpretation; he had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the analysis; and he was responsible for drafting of the article. Dr. Walkey involved in data interpretation and article preparation. Dr. Curran-Everett involved in statistical and data interpretation. Dr. Douglas involved in study design, data interpretation, and article preparation. Drs. Mehta and Douglas were responsible for the study design. Drs. Mehta and Curran-Everett were responsible for the statistical analysis. All authors participated in data interpretation and contributed to critical revisions of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Drs. Mehta, Curran-Everett, Douglas received support for article research from the National Institutes of Health (NIH) (K12HL137862, RHL089897B, and R01NR016459). Dr. Walkey’s institution received funding from the NIH (R01HL136660), and he received funding from UptoDate. For information regarding this article, E-mail: mehtaa@njhealth.org Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Emergency Department to ICU Time Is Associated With Hospital Mortality: A Registry Analysis of 14,788 Patients From Six University Hospitals in the Netherlands Objectives: Prolonged emergency department to ICU waiting time may delay intensive care treatment, which could negatively affect patient outcomes. The aim of this study was to investigate whether emergency department to ICU time is associated with hospital mortality. Design, Setting, and Patients: We conducted a retrospective observational cohort study using data from the Dutch quality registry National Intensive Care Evaluation. Adult patients admitted to the ICU directly from the emergency department in six university hospitals, between 2009 and 2016, were included. Using a logistic regression model, we investigated the crude and adjusted (for disease severity; Acute Physiology and Chronic Health Evaluation IV probability) odds ratios of emergency department to ICU time on mortality. In addition, we assessed whether the Acute Physiology and Chronic Health Evaluation IV probability modified the effect of emergency department to ICU time on mortality. Secondary outcomes were ICU, 30-day, and 90-day mortality. Interventions: None. Measurements and Main Results: A total of 14,788 patients were included. The median emergency department to ICU time was 2.0 hours (interquartile range, 1.3–3.3 hr). Emergency department to ICU time was correlated to adjusted hospital mortality (p < 0.002), in particular in patients with the highest Acute Physiology and Chronic Health Evaluation IV probability and long emergency department to ICU time quintiles: odds ratio, 1.29; 95% CI, 1.02–1.64 (2.4–3.7 hr) and odds ratio, 1.54; 95% CI, 1.11–2.14 (> 3.7 hr), both compared with the reference category (< 1.2 hr). For 30-day and 90-day mortality, we found similar results. However, emergency department to ICU time was not correlated to adjusted ICU mortality (p = 0.20). Conclusions: Prolonged emergency department to ICU time (> 2.4 hr) is associated with increased hospital mortality after ICU admission, mainly driven by patients who had a higher Acute Physiology and Chronic Health Evaluation IV probability. We hereby provide evidence that rapid admission of the most critically ill patients to the ICU might reduce hospital mortality. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Drs. Termorshuizen’s and de Keizer’s institutions received funding from National Intensive Care Evaluation registry, and they received funding from Amsterdam UMC. Dr. Termorshuizen received funding from Mental Health Care Institute, GGZ Rivierduinen and Utrecht University, Utrecht Institute for Pharmaceutical Sciences. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: c.groenland@erasmusmc.nl This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Focused Subspecialty Critical Care Training Is Superior for Trainees and Patients No abstract available

The ED-SED Study: A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients Objectives: To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes. Design: Multicenter, prospective cohort study. Setting: The emergency department and ICUs of 15 medical centers. Patients: Mechanically ventilated adult emergency department patients. Interventions: None. Measurements and Main Results: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of –3 to –5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (SD) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, –0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, –0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26–4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74–2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10–2.73). Conclusions: Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Roberts’ institution received funding from National Heart, Lung, and Blood Institute (NHLBI) K23HL126979. Drs. Roberts, Pappal, Lokhandwala, and Tonna received support for article research from the National Institutes of Health (NIH). Dr. Knight received funding from Bard Medical and Genentech (speaker bureau for both). Dr. Pappal’s institution received funding from National Center for Advancing Translational Sciences of the NIH under Award Number UL1 TR002345. Dr. Johnson’s institution received funding from NHLBI and Medic One Foundation; he received funding from the NIH (U01HL123008-02). Dr. Lokhandwala was supported by NIH/NHLBI T32 HL007287-39. Dr. Hough’s institution received funding from the NIH (U01HL123008-02). Dr. Tonna was supported by a career development award (K23HL141596) from the NHLBI of the NIH, and, in part, by the University of Utah Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, NIH, through Grant 5UL1TR001067-02 (formerly 8UL1TR000105 and UL1RR025764); he received funding from NIH/NSF and Philips Healthcare. Dr. Carpenter disclosed he is a Member of American College of Emergency Physicians Clinical Policy Committee, a Chair of Schwartz-Reisman Emergency Medicine Research Institute International Advisory Board, and a Speaker for Best Evidence in Emergency Medicine (continuing medical education [CME] product) and for Emergency Medical Abstracts (CME product). Dr. Avidan received funding from UptoDate. Dr. Kollef received funding from the Barnes-Jewish Hospital Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest. This work was performed at Washington University School of Medicine in St. Louis, University of Iowa, Cooper University Hospital, University of New Mexico, The Cleveland Clinic, MedStar Washington Hospital Center, Christiana Care Health System, University of Cincinnati, Henry Ford Health System, University of Arizona/Banner University Medical Center-Tucson, Lahey Hospital & Medical Center, University of Washington Harborview Medical Center, University of Utah Health, University of Pennsylvania, Michigan Medicine. For information regarding this article, E-mail: fullerb@wustl.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Evaluation and Predictors of Fluid Resuscitation in Patients With Severe Sepsis and Septic Shock Objectives: Rapid fluid resuscitation has become standard in sepsis care, despite “low-quality” evidence and absence of guidelines for populations “at risk” for volume overload. Our objectives include as follows: 1) identify predictors of reaching a 30 mL/kg crystalloid bolus within 3 hours of sepsis onset (30by3); 2) assess the impact of 30by3 and fluid dosing on clinical outcomes; 3) examine differences in perceived “at-risk” volume-sensitive populations, including end-stage renal disease, heart failure, obesity, advanced age, or with documentation of volume “overload” by bedside examination. Design: Retrospective cohort study. All outcome analyses controlled for sex, end-stage renal disease, heart failure, sepsis severity (severe sepsis vs septic shock), obesity, Mortality in Emergency Department Sepsis score, and time to antibiotics. Setting: Urban, tertiary care center between January 1, 2014, and May 31, 2017. Patients: Emergency Department treated adults (age ≥18 yr; n = 1,032) with severe sepsis or septic shock. Interventions: Administration of IV fluids by bolus. Measurements and Main Results: In total, 509 patients received 30by3 (49.3%). Overall mortality was 17.1% (n = 176), with 20.4% mortality in the shock group. Patients who were elderly (odds ratio, 0.62; 95% CI, 0.46–0.83), male (odds ratio, 0.66; CI, 0.49–0.87), obese (odds ratio, 0.18; CI, 0.13–0.25), or with end-stage renal disease (odds ratio, 0.23; CI, 0.13–0.40), heart failure (odds ratio, 0.42; CI, 0.29–0.60), or documented volume “overload” (odds ratio, 0.30; CI, 0.20–0.45) were less likely to achieve 30by3. Failure to meet 30by3 had increased odds of mortality (odds ratio, 1.52; CI, 1.03–2.24), delayed hypotension (odds ratio, 1.42; CI, 1.02–1.99), and increased ICU stay (~2 d) (β = 2.0; CI, 0.5–3.6), without differential effects for “at-risk” groups. Higher fluid volumes administered by 3 hours correlated with decreased mortality, with a plateau effect between 35 and 45 mL/kg (p < 0.05). Conclusions: Failure to reach 30by3 was associated with increased odds of in-hospital mortality, irrespective of comorbidities. Predictors of inadequate resuscitation can be identified, potentially leading to interventions to improve survival. These findings are retrospective and require future validation. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Supported, in part, by grant from the National Center for Advancing Translational Sciences of the National Institutes of Health through Grant Number 5UL1TR002389-02 that funds the Institute for Translational Medicine. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: maward@medicine.wisc.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Acute Adverse Events After Spinal Cord Injury and Their Relationship to Long-term Neurologic and Functional Outcomes: Analysis From the North American Clinical Trials Network for Spinal Cord Injury Objectives: There are few contemporary, prospective multicenter series on the spectrum of acute adverse events and their relationship to long-term outcomes after traumatic spinal cord injury. The goal of this study is to assess the prevalence of adverse events after traumatic spinal cord injury and to evaluate the effects on long-term clinical outcome. Design: Multicenter prospective registry. Setting: Consortium of 11 university-affiliated medical centers in the North American Clinical Trials Network. Patients: Eight-hundred one spinal cord injury patients enrolled by participating centers. Interventions: Appropriate spinal cord injury treatment at individual centers. Measurements and Main Results: A total of 2,303 adverse events were recorded for 502 patients (63%). Penalized maximum logistic regression models were fitted to estimate the likelihood of neurologic recovery (ASIA Impairment Scale improvement ≥ 1 grade point) and functional outcomes in subjects who developed adverse events at 6 months postinjury. After accounting for potential confounders, the group that developed adverse events showed less neurologic recovery (odds ratio, 0.55; 95% CI, 0.32–0.96) and was more likely to require assisted breathing (odds ratio, 6.55; 95% CI, 1.17–36.67); dependent ambulation (odds ratio, 7.38; 95% CI, 4.35–13.06) and have impaired bladder (odds ratio, 9.63; 95% CI, 5.19–17.87) or bowel function (odds ratio, 7.86; 95% CI, 4.31–14.32) measured using the Spinal Cord Independence Measure subscores. Conclusions: Results from this contemporary series demonstrate that acute adverse events are common and are associated with worsened long-term outcomes after traumatic spinal cord injury. Drs. Jiang and Jaja contributed equally to this work and are co-first authors. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Christopher Reeve Foundation supports the North American Clinical Trials Network for the Treatment of Spinal Cord Injury and the AOSpine Spinal Cord Injury Knowledge Forum. Dr. Grossman received funding from InSightec. Dr. Guest’s institution received funding from North American Clinical Trials Network (NACTN); he received funding from the California Institute of Regenerative Medicine and Abbvie; and he received support for article research from NACTN. Dr. Shaffrey’s institution received funding from NACTN and Zimmer-Biomet, and he received funding from Medtronic, NuVasive, EOS, and Siemens. Dr. Toups’s institution received funding from the Department of Defense Joint Warfare Medical Research Program grant. Dr. Fehlings received funding from Fortuna Fix; he disclosed that the Christopher Reeve Foundation supports the NACTN for the Treatment of Spinal Cord Injury; and he would like to acknowledge support from the Gerry and Tootsie Halbert Chair in Neural Repair and Regeneration and the DeZwirek Family Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: michael.fehlings@uhn.ca Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Comparing the McGrath Mac Video Laryngoscope and Direct Laryngoscopy for Prehospital Emergency Intubation in Air Rescue Patients: A Multicenter, Randomized, Controlled Trial Objectives: Tracheal intubation in prehospital emergency care is challenging. The McGrath Mac Video Laryngoscope (Medtronic, Minneapolis, MN) has been proven to be a reliable alternative for in-hospital airway management. This trial compared the McGrath Mac Video Laryngoscope and direct laryngoscopy for the prehospital setting. Design: Multicenter, prospective, randomized, controlled equivalence trial. Setting: Oesterreichischer Automobil- und Touring Club (OEAMTC) Helicopter Emergency Medical Service in Austria, 18-month study period. Patients: Five-hundred fourteen adult emergency patients (≥ 18 yr old). Interventions: Helicopter Emergency Medical Service physicians followed the institutional algorithm, comprising a maximum of two tracheal intubation attempts with each device, followed by supraglottic, then surgical airway access in case of tracheal intubation failure. No restrictions were given for tracheal intubation indication. Measurements Main Results: The Primary outcome was the rate of successful tracheal intubation; equivalence range was ± 6.5% of success rates. Secondary outcomes were the number of attempts to successful tracheal intubation, time to glottis passage and first end-tidal CO2 measurement, degree of glottis visualization, and number of problems. The success rate for the two devices was equivalent: direct laryngoscopy 98.5% (254/258), McGrath Mac Video Laryngoscope 98.1% (251/256) (difference, 0.4%; 99% CI, –2.58 to 3.39). There was no statistically significant difference with regard to tracheal intubation times, number of attempts or difficulty. The view to the glottis was significantly better, but the number of technical problems was increased with the McGrath Mac Video Laryngoscope. After a failed first tracheal intubation attempt, immediate switching of the device was significantly more successful than after the second attempt (90.5% vs 57.1%; p = 0.0003), regardless of the method. Conclusions: Both devices are equivalently well suited for use in prehospital emergency tracheal intubation of adult patients. Switching the device following a failed first tracheal intubation attempt was more successful than a second attempt with the same device. Drs. Kreutziger and Trimmel drafted, initiated, and designed the study, analyzed and interpreted the data, and drafted the article. Drs. Hornung, Harrer, Urschl, and Doppler assisted in collecting the data and revised the article. Dr. Voelckel participated in concept and design of the study, data interpretation, and critically revised the article. All authors read and approved the final article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Supported, in part, by OEAMTC Helicopter Emergency Medical Service, who paid patient insurance premiums. Dr. Trimmel disclosed that the study was funded in part by Oesterreichischer Automobil- und Touring Club, the motorist association of Austria (OEAMTC) Helicopter Emergency Medical Service (patient insurance fees). The remaining authors have disclosed that they do not have any potential conflicts of interest. Ethics Committee Approval: The study was approved by the Ethics Committee of the State of Lower Austria (GS1-EK-3/124–2016). For information regarding this article, E-mail: Helmut.Trimmel@meduniwien.ac.at This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.